Consent: Shared Decision-Making, Risk, Refusal and Valid Authority
Foundations of consent and shared decision-making
Consent is the patient's permission for a proposed examination, investigation, treatment or other intervention. In good practice it is reached through a decision-making process in which the clinician and patient exchange information, identify what matters to the patient and reach a shared understanding of the available choices. The GMC describes shared...
Learning objectives
• Define consent, shared decision-making and documentation as related but distinct concepts. • Explain why a signed form cannot substitute for meaningful dialogue. • Recognise that valid consent is decision-specific, proportionate and revisitable. • Identify the limits of family involvement and the need for jurisdiction-specific authority when an adult cannot decide.
Consent is a process, not a signature
Consent is the patient's permission for a proposed examination, investigation, treatment or other intervention. In good practice it is reached through a decision-making process in which the clinician and patient exchange information, identify what matters to the patient and reach a shared understanding of the available choices. The GMC describes shared decision-making and consent as fundamental to good medical practice and places the exchange of information at the centre of the process.
A consent form can be useful evidence that a discussion and decision occurred, particularly for significant procedures, but the form is not the consent process itself. The central question is whether the patient had the information, time and support needed for the decision and whether the eventual agreement or refusal was voluntary. A perfectly completed form cannot repair an inadequate conversation.
Three concepts to keep separate
Consent is the patient's decision to accept or refuse. Shared decision-making is the collaborative process used to explore the choices. Documentation is the record of what was discussed, understood and decided. Conflating them causes predictable errors: treating the form as the decision, treating clinician recommendation as patient choice, or assuming that a record proves understanding.
The clinician still has a professional role. Shared decision-making does not mean presenting every imaginable option without guidance. Clinicians identify clinically reasonable options, explain their recommendation and reasoning, describe relevant uncertainty, and make clear that the patient can accept or refuse the recommendation. Recommendation becomes problematic when it turns into pressure.
What a useful consent discussion contains
For a person who can make the decision, the discussion normally includes the diagnosis and prognosis where relevant; the available management options; what each option involves; likely benefits and harms; uncertainties; and the option of no treatment or no change where that is a realistic choice. The discussion should be tailored to the individual rather than limited to a standard list.
Patients should have a realistic opportunity to ask questions. The clinician should listen for priorities that change the significance of an outcome: independence, work, caring responsibilities, communication, mobility, fertility, cognition, pain, or other personal goals may matter differently to different people.
Consent can change
Consent is linked to the specific decision and the circumstances in which it is made. A patient may narrow, pause or withdraw consent. A decision made weeks or months earlier may need review if the condition, risk profile, treatment options or patient preferences have changed. Continuing treatment without checking a material change risks turning an earlier valid decision into an outdated one.
Routine examination can sometimes proceed through clear non-verbal cooperation after an appropriate explanation, but clinicians should not use the idea of implied agreement to bypass discussion when the intervention is significant, intimate, unfamiliar or distressing. If the patient hesitates or asks to stop, that response must be respected and clarified.
Family involvement
Family members, friends and carers may help the patient understand information and express preferences when the patient wants them involved. They can also provide valuable information about the patient's wishes when the patient cannot decide. However, being the next of kin does not by itself create general legal authority to consent to treatment for an adult. The legal framework for decisions when an adult cannot decide differs across the UK and is addressed in greater depth in C4 and C7.
Applied scenarios
Scenario 1
A patient signs a procedure form after receiving a leaflet, but no one has discussed alternatives or what matters most to them. The problem is not simply missing paperwork; the decision process itself is incomplete.
Scenario 2
A relative says, "I am next of kin, so I can sign for him." Clarify that family involvement can be important, but legal authority for an adult who cannot decide must be identified under the applicable framework.
Scenario 3
A patient agreed to surgery three months ago. New renal impairment now materially changes perioperative risk. Revisit the discussion rather than relying on the old form.
Practice checklist
- Name the decision and the reasonable options, including no treatment/no change when relevant.
- Elicit the patient's goals and concerns before deciding which information matters most.
- Explain benefits, harms, uncertainty and why you recommend a particular option.
- Check understanding and invite questions.
- Confirm the choice is voluntary and within the patient's current wishes.
- Record the discussion proportionately and review it when circumstances change.
